HIV in South Africa

South Africa is home to the largest human immunodeficiency virus (HIV) seropositive population in the world1. According to Statistics South Africa, the country has an estimated overall HIV prevalence rate of 13%, and the total number of people living with HIV was estimated at about 7.8 million in 2020. The highest prevalence (18.7%) was among South Africans in the age group 15-49 years2.

Looking back at history

The country’s prevalence rate has remained stable for the past four years. In 2016 an overall HIV prevalence rate of 12.8% was reported. The highest rate was also reported in the age group 15-49 years (19.1%)3.

The 4th South Africa’s National Strategic Plan (NSP) for HIV, Tuberculosis (TB) and Sexually Transmitted Infections (STIs): 2017- 2022, calls for a reduction of mortality and morbidity associated with these diseases by the end of 2022, and the elimination of HIV and TB as public health threats by 20303.

A brief history of HIV/AIDS

In 1981 the American Centres for Disease Control and Prevention (CDC) published an article entitled Pneumocystis Pneumonia – Los Angeles. The article described cases of a rare lung infection, Pneumocystis carinii pneumonia, in five young, previously healthy homosexual men4.

In 1982, the CDC used the term ‘acquired immune deficiency syndrome’ (AIDS) for the first time in an article, and provided the first case definition: ‘A disease at least moderately predictive of a defect in cell-mediated immunity, occurring in a person with no known cause for diminished resistance to that disease’4.

In the same year, the first case of AIDS was reported in South Africa in a white, homosexual male returning from a visit to the United States. Later that year, 250 random blood samples were taken from homosexual men living in Johannesburg, which showed an infection rate of 12.8%5. In 1985, the American National Cancer Institute announced that they have identified the cause of AIDS, a retrovirus they named the human T-lymphotropic virus type III4.

Later that year, the CDC revised their case definition and noted that AIDS is caused by a virus called HIV, which if left untreated can lead to AIDS. Another milestone in 1985 was the development of the first licensed commercial blood test to detect HIV4.

Back home, South Africa reported the first deaths from HIV/AIDS in 1985. In 1987, regulations were issued that added it to the official South African list of communicable diseases. A few months later, the first black South African was diagnosed with HIV5.

In 1988, the South African National Department of Health launched the AIDS Unit and National Advisory Group to promote awareness about HIV/AIDS. Efforts were lackluster to say the least, and by 1990 an estimated 74 000-120 000 South Africans were living with HIV5.

That same year, a national antenatal survey was conducted for the first time and found that 0.8% of pregnant women were infected.

In 1991 a national conference was held and a new body called the Networking HIV&AIDS Community of Southern Africa (NACOSA) was established to develop more comprehensive government policies. The government’s AIDS Unit was dismantled and replaced with the National AIDS Programme5.

By July 1991, the number of HIV/AIDS cases contracted through heterosexual sex was equal to those contracted through homosexual sex, a statistic that challenged widespread prejudice that HIV/AIDS was a ‘homosexual disease.’ From that point on, heterosexual sex became the dominant mode of HIV transmission in South Africa5.

Despite the proven efficacy of antiretrovirals (ARVs) to combat the growing HIV/AIDS epidemic, the South African government refused to roll-out zidovudine to pregnant women, claiming that it was too expensive5.

In 1997 the Inter-Ministerial Committee on AIDS was established with then deputy President Thabo Mbeki as chair. The following year Mbeki was elected President of South Africa. He was extremely vocal in his opinion that HIV did not cause AIDS, but rather that socioeconomic factors were the main drivers. Although his stance was widely criticised, it was supported by members of the ANC – albeit reluctantly5.

Mbeki and then Minister of Health, Dr Manto Tshabalala-Msimang’s views that food like garlic, lemon, African potatoes, and beetroot would be more effective than ARVs to prevent HIV transmission, made international headlines10.

At the end of 1998, the Treatment Action Campaign (TAC) was launched by HIV-positive activist Zachie Achmat, and the battle for the provision of ARVs started in earnest, which would last for much of the following decade. In 2004, following a lengthy campaign by TAC and other AIDS activists, South Africa introduced antiretroviral therapy (ART) in the public sector5.

What progress has South Africa made since the introduction of ART?

Since the introduction of ART, South Africa has indeed made remarkable inroads in the fight against HIV. New infection rates have declined steadily from 360 000 in 2012 to 200 000 in 2019, according to the latest data released by the United Nations Programme on HIV/AIDS. HIV infections in infants have decreased rapidly from about 70 000 in 2004 to less than 6 000 in 20153,11.

Between 2012 and 2016, the HIV mortality rate decreased by almost 5%. By June 2016, more than 3.5 million people with HIV were receiving ART – nearly 50% of those infected3 and in September 2016, a policy of universal test and treat (UTT) was introduced, making ART available to all people infected with HIV regardless of CD4 count. Same-day initiation, advocating ART initiation on the day of a patients’ HIV diagnosis, came into effect in September 20178.

Meeting UNAIDS treatment targets

One of the strategic goals of the NSP is to reduce morbidity and mortality by providing treatment, care, and adherence support for all people infected with HIV. To achieve this, South Africa committed itself to meeting the United Nations Programme on HIV/AIDS (UNAIDS) 90-90-90 fast track targets (published in 2014) in every district of the country3.

The targets:

  • By 2020, 90% of all people living with HIV will know their HIV status
  • By 2020, 90% of all people with diagnosed HIV infection will receive sustained ART
  • By 2020, 90% of all people receiving ART will have viral

A global progress report released by UNAIDS at the end of 2020, shows that in 2019, 81% of people living with HIV knew their status, and 67% were on ART (25.4 million of the 38 million people living with HIV). Almost 59% of people living with HIV globally had suppressed viral loads.

The road ahead

At the end of 2020, UNAIDS extended its initial goals to achieve 95-95-95 by 20309. According to Marinda et al, in order to achieve these goals we need targeted diagnosis, awareness, and treatment programmes for men, young people aged 15-24 years, people who reside in farming communities, and in specific provinces.

References

  1. Satoh S and Boyer HIV in South Africa. The Lancet, vol 394. September 10, 2019.
  2. 2020 Mid-year population estimates. http://www. statssa.gov.za/?p=13453.
  3. National Department of Health. South Africa’s National Strategic Plan for HIV, TB and STIs 2017-2022. https://sanac. za/the-national-strategic-plan/
  4. HIV Gov. A Timeline of HIV and AIDS. https:// hiv.gov/hiv-basics/overview/history/hiv-and-aids- timeline#:~:text=The%20HIV.gov%20Timeline%20reflects,risk%20 for%2C%20HIV%20and%20AIDS
  5. South Africa History Online. A History of Official Government HIV/AIDS Policy in South Africa. https:// hiv.gov/hiv-basics/overview/history/hiv-and-aids- timeline#:~:text=Public%20health%20experts%20predict%20 twice,Immunodeficiency%20Virus%E2%80%9D%20(HIV)
  6. Treatment for all. https://www.unaids.org/en/ resources/909090
  7. 90–90–90: good progress, but the world is off-track for hitting the 2020 targets. https://www.unaids.org/en/resources/presscentre/featurestories/2020/ september/20200921_90-90-90
  8. Marinda E, Simbayi L, Zuma K, et al. Towards achieving the 90–90–90 HIV targets: results from the south African 2017 national HIV BMC Public Health, 2020, 20:1375.
  9. UNAIDS Understanding Fast-Track. Accelerating action to end the AIDS epidemic by 2030. https://www.unaids.org/sites/default/files/media_asset/201506_ JC2743_Understanding_FastTrack_en.pdf
  10. New York Times. Manto Tshabalala-Msimang, South African Who Oversaw Discredited AIDS Policy, Dies at https://www.nytimes.com/2009/12/17/world/ africa/17manto.html.
  11. UNAIDS. South Africa. https://www.unaids.org/en/ regionscountries/countries/southafrica